Instrument Motion Metrics for Laparoscopic Skills Assessment in Virtual Reality and Augmented Reality

A systematic review on classification and assessment of surgical skill levels for simulation-based training programs

BACKGROUND

Nowadays, advances in medical informatics have made minimally invasive surgery (MIS) procedures the preferred choice. However, there are several problems with the education programs in terms of surgical skill acquisition. For instance, defining and objectively measuring surgical skill levels is a challenging process. Accordingly, the aim of this study is to conduct a literature review for an investigation of the current approaches for classifying the surgical skill levels and for identifying the skill training tools and measurement methods.

MATERIALS AND METHODS

In this research, a search is conducted and a corpus is created. Exclusion and inclusion criteria are applied by limiting the number of articles based on surgical education, training approximations, hand movements, and endoscopic or laparoscopic operations. To satisfy these criteria, 57 articles are included in the corpus of this study.

RESULTS

Currently used surgical skill assessment approaches have been summarized. Results show that various classification approaches for the surgical skill level definitions are being used. Besides, many studies are conducted by omitting particularly important skill levels in between. Additionally, some inconsistencies are also identified across the skill level classification studies.

CONCLUSION

In order to improve the benefits of simulation-based training programs, a standardized interdisciplinary approach should be developed. For this reason, specific to each surgical procedure, the required skills should be identified. Additionally, appropriate measures for assessing these skills, which can be defined in simulation-based MIS training environments, should be refined. Finally, the skill levels gained during the developmental stages of these skills, with their threshold values referencing the identified measures, should be redefined in a standardized manner.

Comparison of Attempts Needed for Veterinary Students to Reach Proficiency in a Basic and Advanced Robotic Simulator Task

Surgical training of students is one of the most difficult aspects of veterinary medical education. Competing interests of house officers, owner's wishes, and ethical concerns have led to increasing use of inanimate models for basic surgical skills training. Robotic simulators have benefits for psychomotor training but have not been previously investigated in veterinary medicine. Understanding the necessary practice time for new training devices is important when determining their potential value. The aim of this study was to compare the number of attempts needed for veterinary students to reach proficiency in both a basic and advanced robotic simulator task, and to assess the predictive nature of performance variables. Each student performed a basic and advanced tasks on the Mimic dV-Trainer™ until proficiency was reached. Students required a median of eight attempts (95% CI = 7-8, range: 6-11) to reach proficiency for the basic task versus 22 attempts (95% CI = 20-26, range: 11-62) for the advanced task. The median time required to complete training for the basic and advanced task was 13.5 minutes (range: 8-24 minutes) and 26.5 minutes (range: 11-82 minutes) respectively. The difference in task attempts supports the training protocol and confirms proficiency can be attained in a short period of time. The number of attempts to reach proficiency correlated with specific performance variables which can be used by educators to aid in training students on a robotic simulator. Continued investigations on robotic simulators should be performed to investigate their use in improving psychomotor skills in veterinary students.

Ability to Perform Laparoscopic Intra- and Extracorporeal Suture Ligations in a Live Canine Ovariectomy Model after Simulation Training

Veterinary resident training in minimally invasive surgery is currently inconsistent and depends on innate psychomotor skills. Simulation training has been shown to effectively increase basic skills, but demonstration of simulation training effects on advanced skills in the operating room is sparse. We aimed to determine if simulation-trained novice surgeons were able to perform laparoscopic suture ligation in live dogs. Three novice laparoscopic surgeons underwent a 12-session simulation training program with subsequent laparoscopic skills testing to demonstrate competency. The median skills scores of trainees and of one experienced surgeon were 417 and 472, respectively. Eighteen healthy client-owned (shelter) dogs were operated on by four surgeons: one experienced American College of Veterinary Surgeons (ACVS) diplomate, two novice ACVS residents, and one novice ACVS diplomate. Laparoscopic ovariectomy was performed with suture ligation of the ovarian pedicles. Successful surgery was defined as no evidence of ovarian vessel bleeding after transection of the pedicles. Simulation-trained novices performed successful suture-ligated ovariectomies in 11/13 dogs (85%), and the experienced surgeon in 5/5 (100%) dogs. Median total ligation time was 30 minutes (range: 17-57), which was not different among surgeons (p = .118). Median total surgery time was 105 minutes (range: 69-156) for novices and 89 minutes (range: 65-99) for the experienced surgeon (p = .038). Extensive simulation training including suturing may contribute toward surgery residents being able to perform complex laparoscopic procedures. These results need to be confirmed in larger numbers of trainees.

Comparison of a single-access glove port with a SILS™ port in a surgical simulator model using MISTELS

Background

Recent advances in laparoscopy both in human and veterinary medicine have looked at means of being less invasive by using single-port access surgery as opposed to multiport access surgery. The glove port has gained popularity as a cost-effective alternative to commercially available single-port access devices. The primary aim of this study was to compare the glove port to the SILS™ port in a simulator model using the first two MISTELS (McGill inanimate system for training and evaluation of laparoscopic skills) tasks (peg transfer and pattern cutting).

Methods

Twenty-two novices were enrolled in this experimental study. Each participant had 60 min to practise both MISTELS tasks using two-port laparoscopy. Thereafter participants performed both tasks using the glove and SILS™ port with scores being calculated based on task completion time and errors. Higher scores were indicative of better performance. Participants were assigned into two groups with the starting order of the single ports being randomly selected. A self-evaluation questionnaire with three questions was completed by each participant after testing, rating each port.

Results

Significantly (p < 0.05) higher scores were achieved using the glove port compared to the SILS™ port when performing both tasks. The glove port was subjectively evaluated as easier to use with more manoeuvrability of the instruments than the SILS™ port.

Implications of the study

The glove port’s improved manoeuvrability and ease of use make it a cost-effective alternative to the SILS™ port, for use in single-port laparoscopic veterinary surgery.

Validity and effectiveness of augmented reality in surgical education: A systematic review

BACKGROUND

Current challenges in surgical training have led to the investigation of augmented reality as a potential method of supplementary education. However, its value for this purpose remains uncertain. The aim of this study was to perform a systematic review of the published literature to evaluate the validity and effectiveness of augmented reality in surgical education, and to compare it with other simulation modalities.

METHODS

Electronic literature searches were performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two authors independently extracted pertinent data and assessed study quality. The primary outcome measures of interest were the validity and effectiveness of augmented reality as an educational tool.

RESULTS

Of 6,500 articles, 24 studies met eligibility criteria for inclusion, of which 2 were randomized. Ten studies investigated validity, with 7 establishing both face and content validity and an additional 1 just content validity. Construct validity was demonstrated in 9 of 11 studies. Of the 11 studies that examined the effectiveness of augmented reality in skills acquisition, 9 demonstrated enhanced learning. Of the 5 studies in which the effectiveness of augmented reality as an educational tool was compared with other modes of simulation, augmented reality was found to be superior in 2 and equivalent in the others.

CONCLUSION

Overall, the majority, including 2 high-quality randomized controlled trials, demonstrated the validity and effectiveness of augmented reality in surgical education. However, the quality of published studies was poor with marked heterogeneity. Although these results are encouraging, additional high-quality studies, preferably in the real-life environment, are required before the widespread implementation of augmented reality within surgical curricula can be recommended.

Comparison between intracorporeal and extracorporeal ligations in a laparoscopic ovariectomy model in dogs

OBJECTIVE

To compare the influence of extracorporeal and intracorporeal ligations on the duration of and complications associated with laparoscopic ovariectomy in dogs.

STUDY DESIGN

Prospective randomized experimental study.

ANIMALS

Healthy intact female dogs (n = 18).

METHODS

The left and right ovarian pedicles of dogs undergoing laparoscopic ovariectomy were randomly assigned to intracorporeal (n = 18) or extracorporeal (n = 18) ligation groups. Surgeries were performed by two American College of Veterinary Surgeons (ACVS) diplomates and two ACVS residents. The time required to place extracorporeal and intracorporeal ligations, duration of surgery, and intraoperative complications were compared between ligation techniques. Postoperative complications were recorded.

RESULTS

The time required for intracorporeal ligation (17.3 ± 8.7 minutes) did not differ from that required for extracorporeal ligation (15.1 ± 6.1 minutes; P = .38). The total duration of surgery was 102.7 ± 28.7 minutes including portal placement and veterinary student closure of incisions. Ligation of the ovarian pedicle was successful in 16 of 17 dogs. Intraoperative hemorrhage occurred in three dogs, and postoperative complications were noted in three dogs, without apparent difference between ligation techniques.

CONCLUSION

No difference was identified between extracorporeal and intracorporeal ligations of ovarian pedicles.

CLINICAL SIGNIFICANCE

This study does not provide evidence to support one ligation technique rather than the other.

Objective and automated assessment of surgical technical skills with IoT systems: A systematic literature review

The assessment of surgical technical skills to be acquired by novice surgeons has been traditionally done by an expert surgeon and is therefore of a subjective nature. Nevertheless, the recent advances on IoT (Internet of Things), the possibility of incorporating sensors into objects and environments in order to collect large amounts of data, and the progress on machine learning are facilitating a more objective and automated assessment of surgical technical skills. This paper presents a systematic literature review of papers published after 2013 discussing the objective and automated assessment of surgical technical skills. 101 out of an initial list of 537 papers were analyzed to identify: 1) the sensors used; 2) the data collected by these sensors and the relationship between these data, surgical technical skills and surgeons' levels of expertise; 3) the statistical methods and algorithms used to process these data; and 4) the feedback provided based on the outputs of these statistical methods and algorithms. Particularly, 1) mechanical and electromagnetic sensors are widely used for tool tracking, while inertial measurement units are widely used for body tracking; 2) path length, number of sub-movements, smoothness, fixation, saccade and total time are the main indicators obtained from raw data and serve to assess surgical technical skills such as economy, efficiency, hand tremor, or mind control, and distinguish between two or three levels of expertise (novice/intermediate/advanced surgeons); 3) SVM (Support Vector Machines) and Neural Networks are the preferred statistical methods and algorithms for processing the data collected, while new opportunities are opened up to combine various algorithms and use deep learning; and 4) feedback is provided by matching performance indicators and a lexicon of words and visualizations, although there is considerable room for research in the context of feedback and visualizations, taking, for example, ideas from learning analytics.

Impact of the internet on veterinary surgery

The advent of the internet, and the technological innovations associated with it, have driven significant advances in surgical teaching and learning. The ease of access to information and the variety of online resources allow rapid sharing of surgical knowledge, promoting new teaching and learning patterns. Educational content from online platforms adds theoretical and practical knowledge to accelerate the learning curve and continuing education of surgeons. This study reviews how the advent of the Internet has influenced the teaching and dissemination of knowledge in veterinary surgery.

Validation of Training and Acquisition of Surgical Skills in Veterinary Laparoscopic Surgery: A Review

At present, veterinary laparoscopic surgery training is lacking in experiences that provide a controlled and safe environment where surgeons can practice specific techniques while receiving experts' feedback. Surgical skills acquired using simulators must be certified and transferable to the operating room. Most models for practicing laparoscopic skills in veterinary minimally invasive surgery are general task trainers and consist of boxes (simulators) designed for training human surgery. These simulators exhibit several limitations, including anatomic species and procedural differences, as well as general psychomotor training rather than in vivo skill recreation. In this paper, we review the existing methods of training, evaluation, and validation of technical skills in veterinary laparoscopic surgery. Content includes global and specific scales, and the conditions a structured curriculum should meet for improving the performance of novice surgeons during and after training. A focus on trainee-specific assessment and tailored-technical instruction should influence training programs. We provide a comprehensive analysis of current theories and concepts related to the evaluation and validation of simulators for training laparoscopic surgery in small animal surgery. We also highlight the need to develop new training models and complementary evaluation scales for the validation of training and acquisition of basic and advanced skills in veterinary laparoscopic surgery.

Evaluation of Haptic Feedback on Bimanually Teleoperated Laparoscopy for Endometriosis Surgery

Robotic minimal invasive surgery is gaining acceptance in surgical care. In contrast with the appreciated three-dimensional vision and enhanced dexterity, haptic feedback is not offered. For this reason, robotics is not considered beneficial for delicate interventions such as the endometriosis. Overall, haptic feedback remains debatable and yet unproven except for some simple scenarios such as fundamentals of laparoscopic surgery exercises. Objective: This work investigates the benefits of haptic feedback on more complex surgical gestures, manipulating delicate tissue through coordination between multiple instruments. Methods: A new training exercise, “endometriosis surgery exercise” (ESE) has been devised approximating the setting for monocular robotic endometriosis treatment. A bimanual bilateral teleoperation setup was designed for laparoscopic laser surgery. Haptic guidance and haptic feedback are, respectively, offered to the operator. User experiments have been conducted to assess the validity of ESE and examine possible advantages of haptic technology during execution of bimanual surgery. Results: Content and face validity of ESE were established by participating surgeons. Surgeons suggested ESE also as a mean to train lasering skills, and interaction forces on endometriotic tissue were found to be significantly lower when a bilateral controller is used. Collisions between instruments and the environment were less frequent and so were situations marked as potentially dangerous. Conclusion: This study provides some promising results suggesting that haptics may offer a distinct advantage in complex robotic interventions were fragile tissue is manipulated. Significance: Patients need to know whether it should be incorporated. Improved understanding of the value of haptics is important as current commercial surgical robots are widely used but do not offer haptics.

The Effects of Music on Microsurgical Technique and Performance: A Motion Analysis Study

BACKGROUND

Music is commonly played in operating rooms (ORs) throughout the country. If a preferred genre of music is played, surgeons have been shown to perform surgical tasks quicker and with greater accuracy. However, there are currently no studies investigating the effects of music on microsurgical technique. Motion analysis technology has recently been validated in the objective assessment of plastic surgery trainees' performance of microanastomoses. Here, we aimed to examine the effects of music on microsurgical skills using motion analysis technology as a primary objective assessment tool.

METHODS

Residents and fellows in the Plastic and Reconstructive Surgery program were recruited to complete a demographic survey and participate in microsurgical tasks. Each participant completed 2 arterial microanastomoses on a chicken foot model, one with music playing, and the other without music playing. Participants were blinded to the study objectives and encouraged to perform their best. The order of music and no music was randomized. Microanastomoses were video recorded using a digitalized S-video system and deidentified. Video segments were analyzed using ProAnalyst motion analysis software for automatic noncontact markerless video tracking of the needle driver tip.

RESULTS

Nine residents and 3 plastic surgery fellows were tested. Reported microsurgical experience ranged from 1 to 10 arterial anastomoses performed (n = 2), 11 to 100 anastomoses (n = 9), and 101 to 500 anastomoses (n = 1). Mean age was 33 years (range, 29-36 years), with 11 participants right-handed and 1 ambidextrous. Of the 12 subjects tested, 11 (92%) preferred music in the OR. Composite instrument motion analysis scores significantly improved with playing preferred music during testing versus no music (paired t test, P <0.001). Improvement with music was significant even after stratifying scores by order in which variables were tested (music first vs no music first), postgraduate year, and number of anastomoses (analysis of variance, P < 0.01).

CONCLUSIONS

Preferred music in the OR may have a positive effect on trainees' microsurgical performance; as such, trainees should be encouraged to participate in setting the conditions of the OR to optimize their comfort and, possibly, performance. Moreover, motion analysis technology is a useful tool with a wide range of applications for surgical education and outcomes optimization.